MANAGEMENT OF EPISTAXIS BY DR ANSIYA A ppt

important topic in ENT

1. MANAGEMENT OF EPISTAXIS DR ANSIYA A

2. EPISTAXIS Bleeding from the nose Mainly arterial bleed- main is sphenopalatine artery Venous- 1.anterior retrocollumellar vein in septum 2.woodruffs plexus- venous plexus at posterior end of inferior turbinate

3. SURGICAL ANATOMY OF THE NASAL VASCULAR SYSTEM ARTERIAL SUPPLY OF NOSE

4. VENOUS DRAINAGE

5. The veins follow the arteries within the mucosa Exception-is the periarterial venous cuff surrounding the intra-osseous portions of the inferior and middle turbinate arteries The veins of the lateral wall drain through the sphenopalatine foramen into the pterygoid venous plexus and to the internal jugular vein. Anteriorly -via superior labial and greater palatine veins to the facial vein and ultimately the external jugular system The retro- columellar vein running 2 mm behind and parallelto the columella . (This vein is in a particularly superficial-common cause of venous epistaxis in children

6. WOODRUFF’S PLEXUS a plexus of prominent blood vessels lying just inferior to the posterior end of the inferior turbinate

7. CLASSIFICATION OF EPISTAXIS • Primary: no proven causal factor • Secondary: proven causal factor • Childhood: <16 years • Adult: >16 years • Anterior: bleeding anterior to piriform aperture • Posterior: bleeding point posterior to piriform aperture

8. CAUSES OF EPISTAXIS Traumatic Digital manipulation Nasal fracture/contusion Foreign body in the nose Iatrogenic (e.g., nasogastric tube, surgical interventions)

9. Neoplastic Juvenile nasopharyngeal angiofibroma Tumors of the nasal cavity and paranasal sinuses Hematological Thrombocytopenia Hemophilia A and B Von Willebrand disease Liver failure

10. Structural Mucosal dryness Septal perforation Osler–Weber– Rendu disease (hereditary hemorrhagic telangiectasia ) Drug-related Anticoagulants and antiplatelet drugs Glucocorticoid nasal sprays Nasal consumption of drugs Inflammatory Allergic rhinitis Acute infectious diseases

11. Causes of epistaxis Children – TRAUMA (nose picking -URTI( dryness of nasal mucosa) - FOREIGN BODY ELDERLY - IDIOPATHIC

12. ADULT PRIMARY EPISTAXIS peak presentation is the sixth decade slight male predominance (55 male, 45 female) aetiology of primary epistaxis is unknown but there are clear suggestions that systemic factors may be important

13. Weather : proven association(autumn and winter months) A chronobiological rhythm is also observed the circadian level where onset of bleeding and hospital admission show a biphasic pattern with peaks in the morning and late evening

14. • NSAID: proven association( anti-platelet aggregation effect due to altered plateletmembrane physiology) • Alcohol: proven association-prolongation of the bleeding • Hypertension: no association • Septal deviation: no association

15. SECONDARY EPISTAXIS Trauma Post-surgical Warfarin New oral anticoagulants: TSOACs New target specific oral anticoagulants such as Rivaroxiban and Dabigataran Epistaxis is commonly observed in patients with coagulopathy secondary to liver disease, leukaemia or myelosuppression

16. MANAGEMENT 1.Patient resuscitated, 2.Bleeding slowed, 3.Nasal cavity examined 4.Treatment plan established.

17. MANAGEMENT ALGORITHM

18. FIRSTAID By pinching the ala nasi (the Hippocratic technique) TROTTERS METHOD

19. RESUSCITATION 1.History and examination 2.Assessing the amount of blood lost 3.Intravenous access is established 4.Baseline blood estimations are taken 5.Look for predisposing factors 6.Routine coagulation studies in the absence of a positive history are not indicated

20. ASSESMENT patient should be assessed in a semi-recumbent position and nursing assistance is mandatory. Everyone involved should wear protective visors and clothing as blood aerosol contamination is common Arrange Basic equipment includes:

21. TREATMENT DIRECT THERAPIES-bleeding point specific Therapies Anterior Epistaxis (90%) - controlled with silver nitrate cautery or bipolar Endoscopic control-identifies the source of posterior epistaxis in over 80% of cases enables targeted haemostasis of the bleeding vessel using insulated hot wire cautery or modern single fibre bipolar Electrodes( 90%) Range Monopolar diathermy should not be used in the nasal cavity as there have been reports of blindness due to current propogation

22. INDIRECT THERAPY Nasal packing- tampons ( MerocelR and KaltostatR ) and balloon catheters (Brighton or Epistat ). Hot water irrigation-Irrigation of the nasal cavity with water at 50 °C

23. SYSTEMIC MEDICAL THERAPY Tranexamic acid and epsilon aminocaproic acid – systemic inhibitors of fibrinolysis (contraindicated in pre-existing thromboembolic disease )

24. TOPICAL HAEMOSTATIC AGENTS Topical thrombin Eg - Floseal (Baxter Healthcare) Used as an additional tool

25. SURGICAL MANAGEMENT Surgical management for continued epistaxis consists of: • POSTERIOR PACKING • LIGATION TECHNIQUES • SEPTAL SURGERY TECHNIQUES • EMBOLIZATION TECHNIQUES

26. POSTERIOR PACKING Nasopharyngeal tamponade is achieved using special gauze packs inserted transorally and positioned by means of tapes passed from the posterior choana to the anterior nares bilaterally

27. Antibiotics and opiate analgesia are necessary. P osterior packs should be left in position for a minimum of 48 hours 12 or

28. Complications of posterior nasal packing Considerable pain May cause hypoxia secondary to soft palate oedema Sinusitis Middle ear effusions Necrosis of the septum and columella

29. LIGATION TECHNIQUES Ligation should be performed as close as possible to the likely bleeding point thus the hierarchy of ligation is: • Sphenopalatine artery • Internal maxillary artery • External carotid artery • Anterior /posterior ethmoidal artery.

30. ENDONASAL ENDOSCOPIC SPHENOPALATINE ARTERY LIGATION (ESPAL) 1-GA/LA 2- Incision -8 mm anterior to and under cover of the posterior end of the middle turbinate. 3- Incision is carried down to the bone 4- A mucosal flap is elevated posteriorly until the fibroneurovascular sleeve arising from the sphenopalatine foramen is identified. The foramen can be difficult to identify (its location is signalled by the crista-ethmoidalis ) 5-Identify the vessel 6-ligated using haemostatic clips and divided or coagulated using bipolar diathermy

31. SPHENOPALATINE ARTERY LIGATION

32. Complications of ESPAL Re-bleeding ( anastomoses ) Infection Nasal adhesions

33. INTERNAL MAXILLARY ARTERY LIGATION (IMAL) 1-Trans-antrally via anterior ( sublabial ) or combined anterior and medial (endoscopic) techniques- in to maxillary antrum 2-Mucosa of the posterior wall of the antrum is then elevated 3-A window is made through into the pterygopalatine fossa . 4-The branches of the internal maxillary artery are identified pulsating within the fat of the fossa and are carefully dissected out 5- clipped with haemostatic clips. ( The proximal internal maxillary artery, descending palatine and sphenopalatine branches are all clipped and ideally divided)

34. CALDWELL- LUC’S /SUBLABIAL APPROACH

35. Complications of IMAL Sinusitis Damage to the infra-orbital nerve, Oro- antral fistula Dental damage and anaesthesia Ophthalmoplegia Blindness.

36. EXTERNAL CAROTID ARTERY LIGATION (ECAL) 1-Under GA/LA 2-Skin crease incision / longitudinal incision parallel with the anterior border of the sternomastoid . 3-Identify the carotid bifurcation 4-External carotid confirmed, 5-Double checked for arterial branches and then ligated in continuity

37. ECA ligated above the SUPERIOR THYROID branch to prevent retrogade systemic thrombosis

38. COMPLICATIONS OF ECAL Wound infection Haematoma Neurovascular damage

39. ANTERIOR/POSTERIOR ETHMOIDAL ARTERY LIGATION (EAL) Medial canthal incision Incision is carried down to the bone of the anterior lacrimal crest Using Periosteal elevators- elevate and laterally retract the bulbar fascia. Identify Anterior ethmoidal artery - seen as a fibro-neurovascular mesentry running from the bulbar fascia into the anterior ethmoidal foramen Vessel clipped and divided Dissection is continued to identify the posterior artery which is located approximately 12 mm behind

40. EAL is best reserved as an adjuvant to ESPAL/IMAL/ECAL Or in cases of confirmed ethmoidal bleeding (e.g. ethmoidal fracture, iatrogenic tear)

41. SEPTAL SURGERY Done in epistaxis due toseptal deviation or vomero -palatine spur SEPTOPLASTY OR SUBMUCOSAL RESECTION (SMR) done to access the bleeding point. Some authors have advocated septal surgery as aprimary treatment for failed packing. By elevating the mucoperichondrial flap for septoplasty or SMR, the blood supply to the septum is interrupted and haemostasis secured (SMR and re-packing was found to be more effective and economic than ligation in patients who had failed with packing)

42. EMBOLIZATION Embolization under angiographic guidance has been shown to control severe epistaxis in between 82% and 97%

43. 1-Under local anaesthetic 2-transfemoral Seldinger angiography is used to identify the bleeding points and display the nasal circulation. ( to exclude arteriovenous malformations, aneurysms and fistulae) 3-Bleeding vessel is identified 4-Fine catheter is passed into the internal maxillary circulation and 5-Particles (polyvinyl alcohol, tungsten or steel microcoils ) are used to embolize the vessels. (The ipsilateral facial artery is also embolized in order to prevent re-circulation)

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